Express Scripts Takes on Industry’s Digital Transformation

May 27, 2019

Cigna Corp.’s Express Script PBM expects to introduce the industry’s first stand-alone “digital health formulary” in 2020, the company said May 16. It intends to use a uniform review process to ensure the safety and quality of apps and devices on the market for diabetes, cardiovascular and pulmonary conditions and behavioral health. Such innovation is to be expected following the rash of vertical integration between health insurers and PBMs in recent months, experts tell AIS Health, and building a formulary to vet digital-health tools and integrate them into benefit design is a path other PBMs may follow.

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Cigna Corp.’s Express Script PBM expects to introduce the industry’s first stand-alone “digital health formulary” in 2020, the company said May 16. It intends to use a uniform review process to ensure the safety and quality of apps and devices on the market for diabetes, cardiovascular and pulmonary conditions and behavioral health. Such innovation is to be expected following the rash of vertical integration between health insurers and PBMs in recent months, experts tell AIS Health, and building a formulary to vet digital-health tools and integrate them into benefit design is a path other PBMs may follow.

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Secret Shopper Program Yields Savings, Care Improvements

May 27, 2019

Horizon Blue Cross Blue Shield of New Jersey saw claims savings of $8,000 per practice per month plus improvements in several quality measures when it implemented a “secret shopper” study that evaluated the care given by its primary care providers. The Blues plan says it’s the first time a large health insurer has used undercover shoppers to help physicians evaluate and improve care. But one observer warns this type of program may work for only certain types of carriers.

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Horizon Blue Cross Blue Shield of New Jersey saw claims savings of $8,000 per practice per month plus improvements in several quality measures when it implemented a “secret shopper” study that evaluated the care given by its primary care providers. The Blues plan says it’s the first time a large health insurer has used undercover shoppers to help physicians evaluate and improve care. But one observer warns this type of program may work for only certain types of carriers.

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CMS Fails to Finalize Key Drug Pricing, Management Proposals

May 27, 2019

On May 16, CMS released a final rule on Medicare Advantage (MA) and Part D drug pricing that was notable for actions not taken: The agency didn’t follow through on proposed exceptions to Part D protected drug classes and, after receiving 4,000-plus comments related to pharmacy price concessions on negotiated price, CMS held back on this policy, too, saying it won’t be implemented for 2020. In response, Leerink analyst Ana Gupte told investors that CMS “meaningfully walked back on key provisions in the proposed drug pricing rule from Nov. 2018, pointing to less appetite for the [Trump] Administration to follow through on their reform initiatives in the face of industry opposition.”

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On May 16, CMS released a final rule on Medicare Advantage (MA) and Part D drug pricing that was notable for actions not taken: The agency didn’t follow through on proposed exceptions to Part D protected drug classes and, after receiving 4,000-plus comments related to pharmacy price concessions on negotiated price, CMS held back on this policy, too, saying it won’t be implemented for 2020. In response, Leerink analyst Ana Gupte told investors that CMS “meaningfully walked back on key provisions in the proposed drug pricing rule from Nov. 2018, pointing to less appetite for the [Trump] Administration to follow through on their reform initiatives in the face of industry opposition.”

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by Jinghong Chen The individual insurance market’s financial performance improved more in 2018 than in previous years in the Affordable Care Act exchanges, according to a recent analysis by the Kaiser Family Foundation. The individual market medical loss ratio has improved in recent years and averaged 70% in 2018. Average market gross margins per member […]

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by Jinghong Chen The individual insurance market’s financial performance improved more in 2018 than in previous years in the Affordable Care Act exchanges, according to a recent analysis by the Kaiser Family Foundation. The individual market medical loss ratio has improved in recent years and averaged 70% in 2018. Average market gross margins per member […]

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by Jinghong Chen CMS lacks policies to ensure transparency when states submit major changes to Medicaid Section 1115 waivers, according to a recent report by the Government Accountability Office (GAO). The report said two of the four approvals of new demonstrations GAO reviewed did not obtain public comment on changes that could significantly impact beneficiaries. […]

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by Jinghong Chen CMS lacks policies to ensure transparency when states submit major changes to Medicaid Section 1115 waivers, according to a recent report by the Government Accountability Office (GAO). The report said two of the four approvals of new demonstrations GAO reviewed did not obtain public comment on changes that could significantly impact beneficiaries. […]

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News Briefs

May 27, 2019

✦ Congressional Budget Office (CBO) experts on May 22 told the House Budget Committee that a Medicare for All single-payer health care system likely would give more people coverage but could be “potentially disruptive.” So reports The Hill, which quotes CBO Deputy Director Mark Hadley as saying, “Many more people would probably have health insurance as a result but the government would take much more control over the health care system.” Hadley told Republicans pressing for a cost estimate that “we don’t have an estimate yet,” because how the system is designed would greatly affect the cost.

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✦ Congressional Budget Office (CBO) experts on May 22 told the House Budget Committee that a Medicare for All single-payer health care system likely would give more people coverage but could be “potentially disruptive.” So reports The Hill, which quotes CBO Deputy Director Mark Hadley as saying, “Many more people would probably have health insurance as a result but the government would take much more control over the health care system.” Hadley told Republicans pressing for a cost estimate that “we don’t have an estimate yet,” because how the system is designed would greatly affect the cost.

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